Anticoagulation in the Elderly

Abstract

This review will address the general approach to the management of the typical elderly patient requiring anticoagulation. Most of the data has been derived from studies of patients with nonvalvular atrial fibrillation. Data from postmyocardial infarction trials have also been included. A practical clinical approach to anticoagulation in the elderly is described. Emphasis has been placed on maximizing the benefit and reducing the risk of anticoagulation in the rapidly expanding group of elderly patients aged >/=75 who are at the greatest risk of stroke and are likely to benefit the most from antithrombotic therapy.

The family nurse practitioner role in improving health care for the person over 70 years of age with chronic nonvalvular atrial fibrillation: the exploration of anticoagulation therapy

“…The trial was stopped after 1.1 years when significantly higher rates of ischemic stroke and systemic embolization (7.9% vs. 1.9%) occurred in the combined group (Dhond et al, 2003).…”

“…SP AF III concluded that combination therapy showed no therapeutic benefit and dose-adjusted warfarin therapy was more effective for the patient without causing increased haemorrhagic complications (Dhond et al, 2003;Halperin, 2005;Hart et al, 2007).…”

“…The conclusion drawn from these studies was that the administration of warfarin was the best practice for prevention of stroke in the person who is over the age of 70 years, who has NVAF, and who was at high risk for having a stroke (Dhond et al, 2003;Halperin, 2005;Hart et al, 2007;Mant et al, 2007;Rash et al, 2007;van Walraven et al, 2002;"Warfarin Versus Aspirin," 1994). Stroke prevention in patients with NV AF is paramount, and the optimal management of warfarin therapy must be in the forefront of FNPs minds.…”

“…Despite guidelines and research recommendations consistently identifying the importance and efficacy of warfarin management in older persons who are at high risk of a stroke, numerous research results identify that the majority of patients are not prescribed anticoagulation therapy by the HCP or that anticoagulation therapy has been initiated but remains subtherapeutic (Dhond et al , 2003;Gattelari, Worthington, & Zwar, 2008;Gladstone et al, 2009;Tulner et al, 2010). Consequently, despite the literature stating that warfarin is the best drug therapy for many patients (Dhond et al, 2003 ;Halperin, 2005;Hart et al, 2007;Mant et al, 2007;Rash et al, 2007;van Walraven et al, 2002;"Warfarin Versus Aspirin," 1994), there seems to be a gap between best practice recommendations and HCPs' practice. The following section will present research findings that highlight the fact that the majority of patients are not adequately anticoagulated.…”

“…In Gladstone et al's study, HCPs using the American College of Chest Physicians risk stratification tool (Singer et al, 2008) may not have classified some of the patients as being high risk or requiring warfarin therapy, which would lower the patient's eligibility criteria for this study. All studies I reviewed concluded patients who were at high risk of having a stroke were not being optimally prescribed warfarin therapy or had been managed subtherapeutically (Burton et al, 2001;Dhond et al, 2003;Gattelari et al, 2008;Gladstone et al, 2009;Go et al, 1999;Schumann & Ewigman, 2007;Tulner et al, 20 10), which increases the risk to these older persons for having a stroke.…”